Treating psoriatic arthritis (PsA) is not the same as treating strep throat. You don’t take one medicine for a few days and you feel better. PsA is a complex chronic disease that stays with you and affects many parts of your body – skin, joints, nails, heart and lungs.
Many medications slow PsA and relieve symptoms, but the first treatment you try won’t always be the right one for you.
“There is no one size fits all, and there is no one medication for psoriatic arthritis,” says Sakshi Khatri, MD, professor of dermatology and rheumatology at the Icahn School of Medicine at Mount Sinai in New York. “There are often patients who don’t respond to their medication.”
There are several reasons you might need to switch to a new treatment, says Ethan Craig, MD, assistant professor of clinical medicine at the University of Pennsylvania and a rheumatologist at Michael J. Crescens Medical Center in Philadelphia.
“The first is intolerance — to the patient a side effect of some sort. The second is lack of efficacy. Either the drug doesn’t work in the first place, or it works for a while and then stops working.”
When your medication isn’t taming your symptoms, it’s time to regroup with your rheumatologist or dermatologist and talk about other treatment options.
Signs that it’s time for a change
The most obvious sign that you need to switch medication is new symptoms.
The most obvious symptoms are worsening joint pain and stiffness, increased fatigue, and sudden trouble doing activities that were easy for you. More subtle signs such as difficulty sleeping and mood changes also indicate that the medication you’re taking isn’t adequately controlling your PSA.
If you are just starting therapy, you need to give it time.
Sometimes you can have a partial response – maybe the swelling is in some of your joints but not in others. Then your doctor may suggest that you wait 4 to 6 months to give the medication more time to work. During that time, steroids or non-steroidal anti-inflammatory drugs (NSAIDs) can help bridge the gap until your medication starts.
Once you’ve been on treatment for several months without any improvement, or if you no longer feel comfortable from a medication you’ve been taking for a while, “that’s often an indication that we need to think about turning things around,” Craig says.
Medication switching tips
Psoriatic rheumatism treatment comes in many forms. Anti-inflammatories and conventional disease-modifying drugs (DMARDs) are often used. Biological DMARDS are often used; They target different pathways in the immune system. There are other treatment options as well, including targeted synthetic DMARDS and newer oral agents.
Your doctor will take a few factors into account when recommending the next step, including:
your symptoms. PsA disease causes a variety of symptoms. Your choice of medication may depend on the type of symptoms you have, how bothersome they are, and which drug best targets them.
For example, one of Craig’s patients worked at the box office. “Since he had to hand out tickets, he was very ashamed about the appearance of his nails,” says Craig. “He was willing to take a drug that helped his nails, even if it didn’t help his arthritis.”
Side effects of the drug. Each type of medication comes with its own set of side effects that need to be weighed against their benefits. For example, methotrexate can irritate your stomach, while biologic medications increase the risk of infection. It is important to think about the side effects that you can tolerate and those that you definitely do not want.
How do you take the medicine? Many PsA medications come as an infusion or injection. If you are not a fan of needles, you may prefer the pill.
What other conditions do you have? Methotrexate can damage the liver. NSAIDs are associated with heart problems. So if you already have liver or heart disease, these medications may not be safe for you.
Your insurance coverage. Ultimately, your insurance company can decide what treatment you will have next. “The sad truth of the matter is that our choice of medications is often greatly restricted by insurance approval,” Craig says.
Some insurance companies expect you to try a particular drug first and prove that it doesn’t work before they let you switch to the drug you and your doctor want to use.
How do you ask your doctor about a new treatment?
You may actually see your doctor every 3 to 4 months if you are on medication. During those visits, your doctor can examine your joints, perform imaging tests, and check lab test results to see if your PsA is under good control.
But tests don’t always tell the whole story. Your point of view is also important. Tell your doctor if you have any problems with your medication, including side effects or breakthrough symptoms.
If you don’t need a visit yet, call the office or email your doctor about your concerns through the patient portal.
Don’t be afraid to talk. “A lot of patients hesitate,” Craig says. “They don’t want to take the doctor’s time.” “It helps us to come. I hate to see someone suffer for months. Intervention is often very early in the course of the disease, when things are less active.”
If your doctor isn’t on the plane with you to switch medications, don’t be afraid to back off to get the right treatment. “Sometimes it’s a misunderstanding,” he adds. “We need to be on the same page as to what the expectations are, what we’re dealing with, and the impact we’re expecting.”